Fistulae are First at Kansas Dialysis Services
Scott C. Solcher
Stan Langhofer
Diana Layes
Lynne A. Dryer
Sarah Yelton
Cathy Long

Scott C. Solcher, MD, is nephrologist, private practice, Stormont Vail Healthcare, Lawrence and Topeka, KS, and is Associate Medical Director, Medical Director of Access and the Home Dialysis Programs, Kansas Dialysis Services, Topeka, KS.

Stan Langhofer, BSN, RN, CNN, is Unit Administrator, Kansas Dialysis Services and its satellite facilities, Topeka, KS. He is a board member for the National Renal Administrators Association and a member of the Heart of America Chapter of ANNA.

Diana Layes RN, CNN, is Vascular Access Coordinator, Kansas Dialysis Services, Topeka, KS. She is a member of the Heart of America Chapter of ANNA.

Lynne A. Dryer, ACNP, is Interventional Radiology Advance Practice Nurse, Topeka, KS.

Sarah Yelton, RN, CNN,is Director, Quality Improvement Department, ESRD Network 12, Kansas City, MO. She is a charter member of the Vascular Access Society of the Americas and a member of the Heart of America Chapter of ANNA.

Cathy Long, BA, RHIT,is Quality Improvement Specialist, ESRD Network 12, Kansas City, MO. She is a member of both the American Health Information Management Association and the Kansas Health Information Management Association.

The Fistula First Project was officially activated in July 2003 (Centers for Medicare & Medicaid Services [CMS], 2005). This action put into words and goals the process of re-thinking what the dialysis community would use for permanent hemodialysis access. Over the years, patients on dialysis, nephrologists, access surgeons, and hemodialysis staff members have seen the evolution from Scribner shunts, arteriovenous fistulae (AVFs), numerous types of graft materials and central line catheters, and back to fistulae. The fistula has proven to offer the least problems and the greatest duration remaining the “gold standard” of permanent hemodialysis access. CMS has set goals for each of the 18 End Stage Renal Disease (ESRD) Networks in the U.S. (CMS, 2005). The goal for Network 12 (Iowa, Kansas, Missouri and Nebraska) is 35.1% in prevalent patients and can be found at ESRD Network 12 Web site (2005) (www.Network12.org). The national fistula percentage remains below the 40% K/DOQI goal (U.S. Renal Data System [USRDS], 2004), but that is about to change. The new CMS target is for 66% of prevalent patients to have AVFs by 2009 (CMS, 2005). When we decided to get serious about increasing the number of our patients with functional fistulae, we discovered a complicated puzzle that needed to be put together piece by piece.

Background
(Stan Langhofer, Unit Administrator)
Kansas Dialysis Services (KDS) is a group of five freestanding dialysis centers in Kansas. KDS facilities were founded in 1987 and now serve over 300 patients receiving both incenter and home dialysis. As is typical of our industry, we have a very dedicated group of staff working together to provide the best possible outcomes for our patients (Duda et al., 2000b). We had already succeeded in our anemia, adequacy, and nutritional initiatives and were looking for another battle to fight. What about arteriovenous fistulae? We had long believed in them and recognized how well patients did with them –  but placing fistulae and keeping them functional was out of our control, wasn’t it? We decided to find out.

Armed with the K-DOQI guidelines and the guiding support of our nephrologists, we decided to hold a dinner meeting with area vascular surgeons, and they came. The presentation was simple: (1) Patients did much better with fistulae and (2) Let’s work together to increase the percentage of patients with them. Everyone present agreed, but now what? This was one more goal, one more “thing” to do in a setting that already has many more “things to do” (Spuhler, Schwarze, & Sands, 2002). We determined early on that it would take the support of our entire staff to begin the process and, like anything else, the first step would be the hardest.

Designating a Vascular Access Coordinator
(Stan Langhofer, Unit Administrator)

The process of educating both patients and staff on the benefits fistulae offer was initiated. A “champion” was identified within the dialysis center to be our vascular access coordinator (VAC) and drive the program (Dinwiddie, 2003). Whom do you pick? For any important project you must have a knowledgeable, experienced person with a passion for the subject, and, in our unit, Diana Layes accepted the position. With the organizational support of our governing body, KDS began to allocate time to her for work on this purpose. Not a lot at first, a day here, a day there – but when we started to see results, we got excited and it was like a snowball rolling down hill. Now the majority of her time is spent in this area, and the benefits are incredible!

Fistulae Increased at KDS
(Stan Langhofer, Unit Administrator)
Let us give you some of the results of our work and then identify for you the specific steps we took to get there. In October 2001, 39% of our patients had fistulas, 35% had grafts, and 26% had catheters. As you can imagine, nobody was asking us to give any lectures or publish any articles. By February 2005, just a little over 3 years later, 62% of our patients had fistulas, 18% had grafts and 20% catheters (see Figure 1). This represented a 23% absolute increase in fistulae and was a very big achievement that will benefit our patients for years to come. In addition, over half of our catheter patients have a developing fistulae in place. When those fistulae mature and are being used, our fistula percentage could reach 72%. It is our belief that other facilities can experience similar improvements.

Role of the Vascular Access Coordinator at KDS
(Diana Layes, VAC)
The role of the vascular access coordinator (VAC) is multifocal. Primarily, the VAC is a patient advocate. With the knowledge that the AVF offers the patient on dialysis the best long-term access, the VAC should view all persons needing hemodialysis access as potential fistula recipients. Early education, and, if possible, pre-dialysis education with modality and access options give the VAC the opportunity to discuss the different accesses available with the pros and cons of each. The time of initial hemodialysis treatment is often filled with confusion, fear, doubt, and physical illness and is not the best time for the patient to make decisions. If access information is available in written form, the patient, family, and trusted friends can read and discuss the information at a less stressful time. Given the advantages of the AVF, most persons planning hemodialysis choose to have a fistula placed.

The VAC must provide education for the staff as well as for the patients on dialysis. The newly placed AVF needs to be assessed for thrill, bruit, and maturation on a frequent and scheduled basis. Staff education is ongoing and all staff should have annual skills review, which should include access assessment and cannulation techniques. Each staff member brings his/her unique talents to the dialysis unit and some are better at cannulation of difficult accesses than others. To promote AVF longevity, “expert cannulators” are used to initiate dialysis for at least the first 6 treatments or until the fistula is deemed adequately mature by the VAC.

An important role for the VAC is supervising access monitoring. Monitoring of the hemodialysis access can be performed using any number of techniques from simple to sophisticated. Dynamic venous pressure monitoring is an acceptable technique of monitoring according to K-DOQI recommendations (National Kidney Foundation [NKF], 2001). It is easily performed, needs no special equipment, and takes only minutes to complete. It is very cost efficient, requiring only manpower to collect and evaluate the data, and we perform it every treatment. Along with venous monitoring, the KT/V and machine pressures are evaluated for change. When intervention is needed, it is discussed with the patient and plans are documented in the medical record. Further communication by a written note to the patient details what intervention is planned as well as when and where it will occur. The written note includes any special intervention preparation needed and who will receive reports of the procedure (see Figure 2). The nephrologists and/or the access surgeon are also sent a memo informing them of the proposed procedure (see Figure 3). The VAC completes the access referral form (see Figure 4) and sends it prior to any intervention. It introduces the patient, gives brief information regarding the problem, and lists the patient’s nephrologist and surgeon. It also lists current meds, current blood tests of interest, and “nice to know” information. After each intervention, the results are documented into the medical record (see Figure 5). The patient is informed of the results, what treatment was performed, and any requested follow-up. Additionally, this discussion is supplemented in written form and a picture, for clarification, is given for the patient to retain. The VAC assures that the nephrologists and/or access surgeon have copies of any results of procedures performed as well as information on any further intervention needed.

Hemodialysis access quality improvement is reviewed monthly by our administrative team and at our access team meeting every other month. The access team consists of nephrologists, dialysis nurses, access surgeons, interventional radiologists, interventional radiology nurse practitioner, dialysis administrator, and other interested physicians (Duda et al., 2000a; Nguyen, Griffith, & Treat, 2003). These well-attended meetings, which take place at the KDS, provide a unique forum for communication between all interested parties.

Communication is essential to the process and the VAC is the “go to” person, like the hub of the wheel, who is available to patients, staff, and physicians. It is also important to have a good working relationship with interventional radiology and the vascular surgeons. With everybody working together much progress can be made.

The VAC From a Nephrologist’s Perspective
(Scott Solcher, Nephrologist)
From a physician’s standpoint, an access coordinator is simply an enormous step toward achieving ideal hemodialysis access for patients. The goals expected are easier to talk about than they are to achieve, with multiple roadblocks present. An access coordinator relieves some of these issues.

For the nephrologists, the challenge is to get timely referrals of persons with chronic kidney disease (CKD) before patients are in need of emergent dialysis therapy. When nephrologists have a chance to provide care for the person with CKD, they can more easily get the patient to a vascular access surgeon for fistula placement. The longer the AVF has to mature before it is needed, the less chance a catheter will be needed urgently.

In general, prior to dialysis, the control over when and which surgeon used to place a fistula is made in the outpatient office setting. After the initiation of dialysis, however, that shifts to the dialysis unit. Like most settings, we have an artificial barrier between the physician’s office and the dialysis units. Communication is more difficult, and the logistics change. Which surgeon placed the access? Which hospital does the patient use? Has the patient had radiographic intervention already? What is the indication for intervention now? The dialysis unit staff, rather than office staff, best answer all of these questions. Arranging these procedures can be time consuming, and would get done more slowly if most physicians were responsible for arranging them, at least they would if I were doing it alone.

That said, I believe that fistula rates are a “substitute endpoint.” A substitute endpoint is when something is measured to approximate some other more significant outcome. For example, coronary artery stenoses are a substitute for myocardial infarction, morbidity, and mortality. A narrowed artery is more likely to be associated with a bad outcome. A fistula in and of itself does not necessarily make the patient “better.” The fistula may fail or take months to mature, patients are expected to exercise them, and a fistula often is harder to cannulate than a graft.

Fistula rates, then, are primarily a substitute endpoint for hospitalization. Certainly, there are data that higher fistula rates are associated with less mortality, but most patients don’t die from access failure. Those without fistulae are admitted to the hospital frequently, however, for sepsis and surgery. These are the admissions that are prevented by more fistulae. About sixty percent (60%) of our patients have fistulae now, and about forty-five percent (45%) did in 2002. Our retrospective, standardized ratio of admission to expected admissions from 2002 was 0.52. I believe that most of the reduction in admissions is attributable to our higher fistula rates.

With the help of our access coordinator, our fistula rates have risen and we all expect them to rise further. As that happens, our patients will be healthier, the dialysis unit will flow more smoothly, and I will have less logistics to worry about.

Interventional Radiology
(Lynn Dryer, IR Nurse Practitioner)

The VAC schedules fistulograms on a nondialysis day, if possible, so that if the Interventional Radiologist (IR) is running behind schedule, the patient’s’ dialysis treatment will not be interfered with. The VAC sends an access referral form (see Figure 4) to the Interventional Radiology Nurse Practitioner (IRNP), which is a valuable communication tool, along with the allergy and medication information for each patient. This form notes the access site, the patient’s code status, and special considerations for each particular patient. It also identifies which physicians need copies of the report forwarded to them. The form is then placed in the patient’s chart and made available at the hospital both pre and post procedure.

A preprocedure instruction sheet (see Figure 2) was also developed so the VAC can give written instructions to the patient. This helps the patient comply with orders that, if not followed, may delay or cancel the case.

The IR report goes to the dialysis unit as well as to the nephrologists’ and surgeons’ offices so that they will have the latest access information allowing them to keep better track of what is happening with their patients. The IR nurse practitioner has helped facilitate this process, which has enhanced access team communication. The VAC also follows these reports allowing for consistent patient care. This process has improved the surveillance and longevity of all accesses, but especially of high-risk accesses like new AVFs.

Communication between the VAC and the IRNP makes both the dialysis unit and IR more efficient, minimizes access problems, and improves staff and patient satisfaction. The access team has improved our understanding of each other’s roles and how we can work together to continue to increase the number of fistulae, which is the underlying goal. The bottom line is better patient care.

Conclusion
(Stan Langhofer, Unit Administrator)
This article has detailed how the VAC, Unit Administrator, Nephrologist, Surgeon, Interventional Radiology Nurse Practitioner, and Interventional Radiologist work together to provide the patient with continuity of vascular access care. We recommend, based on our experience, that you not let the CMS goal of having 66% of patients with AVFs by June 2009 scare you, but rather use it as you communicate with your healthcare team as the motivation to truly make “fistulae first.”

In summary, approach this project one step at a time like any big job. Recognize the challenge, define your goals, allocate appropriate resources, develop a strategy, work hard, collect data, meet regularly to assess the process and review your progress. Our guess is that you’ll like the results.

Editor’s Note: The KDS Fistulae rate has continued to climb and currently meets the 2009 CMS target rate of 66%.

References
Centers for Medicare & Medicaid Services (CMS). (2005). Fistula first change package – Vascular access for hemodialysis: Increasing the incidence and prevalence of AV fistulas. Retrieved June 22, 2006, from www.fistulafirst.org/conceptlg.htm

Dinwiddie, L.C. (2003). Investing in the lifeline: The value of a vascular access coordinator. Nephrology News & Issues, 17(5), 49-53.

Duda, C.R., Spergel, L.M., Holland, J., Tucker, C.T., Bander, S.J., & Bosch, J.P. (2000a). How a multidisciplinary vascular access care program enables implementation of the DOQI guidelines. Part I. Nephrology News & Issues, 14(5),13-17.

Duda, C.R., Spergel, L.M., Holland, J., Tucker, C.T., Bander, S.J., & Bosch, J.P. (2000b). Implementing a vascular access quality improvement program: Part II: Lessons learned. Nephrology News & Issues,14(6), 29-32.

ESRD Network 12. (2005). Clinical Performance Measures (CPM) goal worksheet. Retrieved June 22, 2006, from http://www.network12.org/qi_projects/cpm_2005_goals_worksheet.pdf

National Kidney Foundation (NKF). (2001). K/DOQI clinical practice guidelines for vascular access: Guideline 14. American Journal of Kidney Disease, 37, S1, S157.

Nguyen, V.D., Griffith, C., & Treat, L. (2003). A multidisciplinary team approach to increasing AV fistula creation. Nephrology News & Issues, 17(7), 54-56, 58, 60.

Spuhler, C.L., Schwarze, K.D., & Sands, J.J. (2002). Increasing AV fistula creation: The Akron experience. Nephrology News & Issues, 16(5), 44-49.

U.S. Renal Data System (USRDS). (2004). USRDS 2004 Annual Data Report. Retrieved June 22, 2006, from www.usrds.org